<%@ page language="java" contentType="text/html; charset=UTF-8"
    pageEncoding="UTF-8"%>
    <%
    String path=request.getContextPath();
    String basePath = request.getScheme()+"://"+request.getServerName()+":"+request.getServerPort()+path+"/";
    %>
<!DOCTYPE html>
<html>
  
  <head>
    <meta charset="UTF-8">
    <title>欢迎页面-X-admin2.0</title>
    <meta name="renderer" content="webkit">
    <meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1">
    <meta name="viewport" content="width=device-width,user-scalable=yes, minimum-scale=0.4, initial-scale=0.8,target-densitydpi=low-dpi" />
    <link rel="shortcut icon" href="/favicon.ico" type="image/x-icon" />
    <link rel="stylesheet" href="./css/font.css">
    <link rel="stylesheet" href="./css/xadmin.css">
    <script type="text/javascript" src="https://cdn.bootcss.com/jquery/3.2.1/jquery.min.js"></script>
    <script type="text/javascript" src="./lib/layui/layui.js" charset="utf-8"></script>
    <script type="text/javascript" src="./js/xadmin.js"></script>
    <!-- 让IE8/9支持媒体查询，从而兼容栅格 -->
    <!--[if lt IE 9]>
      <script src="https://cdn.staticfile.org/html5shiv/r29/html5.min.js"></script>
      <script src="https://cdn.staticfile.org/respond.js/1.4.2/respond.min.js"></script>
    <![endif]-->
  </head>
  
  <body>
  	<div class="x-nav">
      <span class="layui-breadcrumb">
        <a href="">首页</a>
        <a href="">进度审核</a>
        <a>
          <cite>申请中心</cite></a>
      </span>
      <a class="layui-btn layui-btn-small" style="line-height:1.6em;margin-top:3px;float:right" href="javascript:location.replace(location.href);" title="刷新">
        <i class="layui-icon" style="line-height:30px">ဂ</i></a>
    </div>
      <div style="text-align: center; margin-top: 1%"><h1>中国平安车险垫付申请中心</h1></div>
    <div class="x-body">
    	<xblock>
     
      </xblock>
        <form class="layui-form" method="post" action="Advanced2.html">
          <div class="layui-form-item">
              <label for="username" class="layui-form-label">
                  <span class="x-red">*</span>驾驶人姓名:
              </label>
              <div class="layui-input-inline"> 
                   <input type="text"  name="driverName" value="" placeholder="请输入驾驶人姓名"  required="姓名不能为空" class="layui-input"/>
              </div>
              <div class="layui-form-mid layui-word-aux">
                  <span class="x-red">*</span>将会成为您申请的重要信息
              </div>
          </div>
          <div class="layui-form-item">
              <label for="phone" class="layui-form-label">
                  <span class="x-red">*</span> 地址:
              </label>
              <div class="layui-input-inline">	
              	  <input type="text" value=""  name="dangerAddress" required="地址不能为空" placeholder="请输入事故地址" class="layui-input"/>
                 
              </div>
              <div class="layui-form-mid layui-word-aux">
                  <span class="x-red">*</span>将会成为您申请的重要依据
              </div>
          </div>
          <div class="layui-form-item">
              <label for="L_email" class="layui-form-label">
                  <span class="x-red">*</span>车牌:
              </label>
              <div class="layui-input-inline">			
              	  <input type="text" name="carNo" value=""placeholder="请输入车辆牌照" required="车牌不能为空" class="layui-input" pattern="^[京津沪渝冀豫云辽黑湘皖鲁新苏浙赣鄂桂甘晋蒙陕吉闽贵粤青藏川宁琼使领A-Z]{1}[A-Z]{1}[A-Z0-9]{4}[A-Z0-9挂学警港澳]{1}$" />
                 
              </div>
              <div class="layui-form-mid layui-word-aux">
                  <span class="x-red">*</span>事故车辆牌照
              </div>
          </div>
             <div class="layui-form-item">
              <label for="L_email" class="layui-form-label">
                  <span class="x-red">*</span>手机:
              </label>
              <div class="layui-input-inline">												
           <input   class="layui-input" type="text" value="" placeholder="请输入手机号码"  name="driverTel" class="layui-input" pattern="^1[34578][0-9]{9}$" required="姓名不能为空"/>             
              </div>
              <div class="layui-form-mid layui-word-aux">
                  <span class="x-red">*</span>驾驶人手机号
              </div>
          </div>
             

             <div class="layui-form-item">
              <label for="L_email" class="layui-form-label">
                  <span class="x-red">*</span>金额:
              </label>
              <div class="layui-input-inline">                             
           <input type="text" value="" placeholder="请输入垫付金额:单位(元)"  class="layui-input" pattern="^([1-9]\d{0,9}|0)([.]?|(\.\d{1,2})?)$"/>            
              </div>
              <div class="layui-form-mid layui-word-aux">
                  <span class="x-red">*</span>(必填)
              </div>
          </div>   
          
           <div class="layui-form-item">
              <label class="layui-form-label"><span class="x-red">*</span>责任认定通知书:</label>
              <div class="layui-input-block">
                <input type="radio" name="notice" lay-skin="primary" title="是" checked>
                <input type="radio" name="notice" lay-skin="primary" title="否">
       
              </div>
          </div>
           <div class="layui-form-item">
              <label class="layui-form-label"><span class="x-red">*</span>垫付证明通知书:</label>
              <div class="layui-input-block">
                <input type="radio" name="notice2" value="是" title="是" checked>
                <input type="radio" name="notice2" value="否" title="否">
       
              </div>
          </div>
          
          <div class="layui-form-item">
              <label for="L_repass" class="layui-form-label">
              </label>
         
                  <input type="submit" name="" id="" value="提交" class="layui-btn" />                                                           
           
          </div>
        
      </form>
    </div>
    
  
  </body>

</html>